Multidisciplinary Management for Large and Difficult Choledocholithiasis: The Role of Choledochotomy

Authors

Jilpa Shah, HCA HealthcareFollow
Balu Chandra

Files

Division

North Texas

Hospital

Medical City Arlington

Specialty

Internal Medicine

Document Type

Presentation

Publication Date

2024

Keywords

Choledocholithiasis, Bile duct diseases, Choledochotomy

Disciplines

Digestive System Diseases | Internal Medicine | Medicine and Health Sciences | Surgical Procedures, Operative

Abstract

Extracranial carotid artery aneurysm is a rare sequela of atherosclerosis, trauma, and conditions of chronic inflammation. Standard treatments include antiplatelet medications, open resection, or endovascular stenting. Transcarotid artery revascularization (TCAR) has become a well-recognized alternative treatment in the past few decades. This case study documents the first reported case of Horner’s syndrome post-TCAR for an internal carotid artery (ICA) aneurysm. A 68 year-old male with intermittent double vision was referred to vascular surgery clinic with brain CT angiography showing a 9mm saccular aneurysm with dissection flap of the right cervical ICA. Prior attempts by neuro-interventional radiology were unsuccessful due to tortuous anatomy. After lengthy discussion with the patient, the decision was made to proceed with TCAR. The TCAR procedure was conducted with flow reversal from the right common carotid artery (CCA) to the left femoral vein. A Iliac covered stent, arterial stent was used to stent the lesion. Angiography demonstrated a small dissection at the cavernous segment of the internal carotid artery (ICA). A second stent was placed across the dissection. The completion angiogram showed no residual lesions. Patient was monitored in the ICU postoperatively. A few hours following the procedure, the patient began to complain of a significant frontal headache despite strict blood pressure control. A CT head was completed without any acute findings. Post-op day 1, the patient developed Horner’s syndrome with symptoms of mild right eye ptosis, anisocoria with excessive right eye tearing, and flushing of the face. Post-op day 2, the patient remained stable with persistent Horner’s symptoms. The patient was discharged with tapered methylprednisolone sodium succ regimen with planned close follow up in the clinic. At two-week follow-up, the patient’s symptoms had nearly resolved Horner’s syndrome has been documented as a rare complication following other endovascular carotid procedures. Stretching of the sympathetic fibers that course along the carotid artery is thought to be the cause of this rare complication. Treatment is generally supportive, but there has been documented cases of steroid use. The case highlighted describes a rare and previously undocumented complication of TCAR in high carotid artery lesions. This case will further help understand the possible complications of performing the TCAR procedure and assist in patient selection and treatment discussions for future carotid artery lesions.

Original Publisher

HCA Healthcare Graduate Medical Education

Recommended Citation

Shah, Jilpa and Chandra, Balu, "Multidisciplinary Management for Large and Difficult Choledocholithiasis: The Role of Choledochotomy" (2024). North Texas GME Research Forum 2024. 8.
https://scholarlycommons.hcahealthcare.com/northtexas2024/8